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Oncology emergencies (Mass effect (Spinal cord compression (Treatment…

- - - - Thoracic vertebrae are most common with ~10% of noncontiguous mets at other vertebra -> whole spine imaging for survey (C-spine mets is uncommon, some may preclude its imaging if lack of sx)
      - C-spine mets common origin: Lung, breast, and prostate cancers and lymphoma and multiple myeloma
    - - Reduce edema and inflammation
        
        Dexamethasone 10mg IV -> 4mg PO/IV Q6H (do not wait until imaging if highly suspected)
      - Pain control
      - Reduce tumor size
        
        Emergent radiotherapy (~90% ambulatory remains ambulatory; 50% cannot walk alone regain ambulation; a few with paraplegia regain LE function)
  - - - lung, breast, melanoma, leukemia, lymphoma; also postR/T, C/T
  - - - Cancer extrinsic compression
        
        70% lung, 20% lymphoma
      - iatrogenic
        
        indwelling catheter placement, pacemaker leads
    - - Reduce venous congestion
        
        head elevation (to decrease ICP)
        
        Corticosteroid, loop diuretics (insig clinical efficience)
      - make a hole
        
        intravascular stent
      - Reduce tumor size
        
        chemotherapy (relief sx in 80% of lymphoma, 80% of SCLC, 40% of NSCLC)
        
        radiotherapy (relief sx in 75% at D3)
- - - - PTH related protein production
      - osteoclastic activity, such as w/ bone mets
        
        lung, breast, MM (these 3 most common)
      - vit D analogue production
        
        Hodgkin's lymphoma
    - - Remove Ca
        
        Furosemide (do not use routinely), only for those with limited cardiopul capacity)
        
        Saline hydration (Ca is osmotic diuresis, and it usually happens in advanced cancer means cachexia) w/ 1~2L bolus, then 200~250cc/h IF
        
        hemodialysis
      - Reduce bone resorption and renal absorption
        
        Bisphosphonates
        
        Action: sustained decrease in Ca in 12~48h, last for 2~4 weeks
        
        SE: bisphosphonate-Ca complex deposition in kidney -> RF if given too rapidly
        
        Calcitonin (limited role in malig): 4U/kg SC/IV, q12h
        
        Action: lower Ca in 2~4h
        
        SE: tachyphylaxis in 3 days, hypersensitivity response
      - Prednisone 60mg/d PO, may helpful in steroid-sen tumor, e.g. lymphoma, MM
  - - - SIADH (euvolemic)
        
        Treatment
        
        mild >125
        
        water restriction to 500c/d
        
        mod 110~125
        
        Furosemide 0.5~1mg/kg PO + IV NS
        
        severe <110 or seizure
        
        3% saline at 25~100c/h
    - - CNS
        
        Seizure, usually GTC; survey for intracranial lesion if focal
  - - - hyperkalemia
        
        dysrhythmia
      - hyperP (malign cells had 4X increase of P) -> hypocalcemia
        
        CaP crystal in renal tubes
        
        AKI
        
        seizure, tetanus
        
        Prophylactic hydration; treat hyperP with dextrose and insulin; phosphate binder is limited
      - nucleic acid -> uric acid
        
        urate precipitate in renal tubules
        
        AKI
        
        Prophylaxis with allopurinol, hydration
- - - - Severe: ANC<500
      - Profound: ANC<100
    - - Empirical abx if ANC<500; if ANC 500~1000 w/ risk factor for bac infection; >1000 limited evidence (median fever 2d for low risk, 5~7d for high risk after abx)
        
        Add vancomycin if hemodynamic instability, radiographic pneumonia, catheter-related infection, skin or soft tissue infection, known coloniza- tion with resistant gram-positive organism
    - - hospitalization criteria
        
        Expected profound neutropenia >7d
        
        Multiple comorbidities
        
        AKI, liver injury
        
        Non low risk score: Multinational Association for Supportive Care in Cancer Risk Index or Clinical Index of Stable Febrile Neutropenia tool
    - - 60% GPC
        
        S.a, S. viridians, CONS, enterococcus
      - GNB
        
        E.coli, KP, P.a
  - - - Hct >60%
        
        polycythermia
      - WBC>100K
        
        leukemia
      - abnl plasma content
        
        Waldenström’s macro- globulinemia and Ig A–producing myeloma
    - - Hydration (dehydration exacerbates)
      - Plasmapheresis / Leukapharesis